Text Messages With Financial Incentives for Men With Obesity: A Randomized Clinical Trial

Importance

Effective weight loss interventions are needed for men with obesity.

Objective

To determine whether an intervention that combined text messaging with financial incentives attained significant weight loss at the 12-month follow-up compared with the control group and whether an intervention of text messaging alone attained significant weight loss at the 12-month follow-up compared with the control group.

Design, Setting, and Participants

An assessor-blinded randomized clinical trial conducted in Belfast, Bristol, and Glasgow areas in the UK. A total of 585 men with body mass index (BMI) of 30 or more were enrolled between July 2021 and May 2022. Final follow-up occurred June 2023.

Interventions

Participants were randomly assigned to 12 months of behavioral focused text messages combined with financial incentives (n = 196), 12 months of behavioral focused text messages alone (n= 194), or a waiting list (control group; n= 195). The financial incentive consisted of a monetary reward that was lost if weight loss targets were not met. All participants received weight management information and a pedometer at baseline.

Main Outcomes and Measures

The 2 primary comparisons were the 12-month comparison of within-participant weight change between the text messaging with financial incentive group and the control group and the comparison between the text messaging alone group and the control group (minimum clinically important difference, 3%). The P value defined for statistical significance was P < .025 for each comparison.

Results

Of the 585 men (mean [SD] age, 50.7 [13.3] years; mean weight, 118.5 [19.9] kg; mean BMI, 37.7 [5.7]; 525 [90%] White), 227 (39%) lived in postal code areas with lower socioeconomic status, and 426 (73%) completed the 12-month follow-up. At the 12-month follow-up, compared with the control group, the mean percent weight change was significantly greater in the text messaging with financial incentive group (mean difference, -3.2%; 97.5% CI, -4.6% to -1.9%; P < .001) but was not significantly greater in the text messaging alone group (mean difference, -1.4%; 97.5% CI, -2.9% to 0.0, P = .05). The mean (SD) weight changes were -5.7 (7.4) kg for the text messaging with financial incentives group, -3.0 (7.5) kg for the text messaging alone group, and -1.5 (6.6) kg for the control group. The 12-month mean (SD) percentage weight changes from baseline were -4.8% (6.1%) for the text messaging with financial incentives group, -2.7% (6.3%) for text messaging alone group, and -1.3% (5.5%) for the control group. Of 366 adverse events reported, the most common were infections (83 [23%]). Of the 23 serious adverse events (6.3%), 12 (52%) occurred in the text messaging with financial incentives group, 5 (22%) in the texts messaging alone group, and 6 (26%) in the control group. None were considered related to participating in a trial group.

Conclusion and Relevance

Among men with obesity, an intervention with text messaging with financial incentive significantly improved weight loss compared with a control group, whereas text messaging alone was not significantly better than the control condition. These findings support text messaging combined with financial incentives to attain weight loss in men with obesity.

Trial Registration

isrctn.org Identifier: ISRCTN91974895.

Exploring the world of food with families: perspectives of low-income families on factors influencing their food choices

OBJECTIVE

The aim of this study was to investigate the social and environmental factors involved in the food decision-making processes of families living on lower incomes on the Island of Ireland.

DESIGN

A qualitative design was employed for this study, using photovoice and creative mapping methods. Parents were requested to take photos and draw maps of their food environments. Interviews were then conducted with parents, using the materials produced by parents as a cue to discuss their food environments, influences and decision-making processes around food choices.

SETTING

The participants were interviewed online via Microsoft Teams.

PARTICIPANTS

The participants were parents or guardians of children between the ages of 2 and 18 who self-defined as 'living on a tight budget'.

RESULTS

Twenty-eight participants were recruited and interviewed for this study, including twelve parents in Northern Ireland and sixteen in the Republic of Ireland. The findings were mapped on to Bronfenbrenner's Ecological Systems Theory and showed that multiple, overlapping and intersecting factors at the individual, micro-, meso-, exo-, macro- and chrono-system were implicated in family food choices. Upstream factors in particular, including structural, policy and commercial determinants, appear to be significant drivers of behaviour.

CONCLUSIONS

While the findings suggest that a complex range of factors are involved in family food choices, it is clear that policy measures and regulations are needed to stave off the impacts of rising social inequality and food poverty. Health promoters should strive to find non-stigmatising interventions to bridge the nutritional divide experienced by lower-income families.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

First-trimester glycaemic markers as predictors of gestational diabetes and its associated adverse outcomes: A prospective cohort study

OBJECTIVE

Gestational diabetes mellitus (GDM) is associated with excessive fetal growth in later gestation. Recent data suggest accelerated growth may begin before 28 weeks' gestation when GDM is typically diagnosed. The identification of pregnancies at risk of early fetal growth would enable early intervention. We assessed the use of early pregnancy HbA1c in predicting excessive fetal growth.

RESEARCH DESIGN AND METHODS

Women were recruited at antenatal booking from a major maternity unit in the UK. HbA1c was measured at <14 weeks gestation in 1243 women at risk of GDM as defined by UK NICE risk factors of whom 1115 underwent OGTT. Women with previous GDM were excluded. Comprehensive fetal ultrasound was performed at 28 weeks' gestation alongside 75 g OGTT in 976 of these women. GDM was defined using WHO criteria. Pregnancy outcomes were extracted from the regional maternity care database.

RESULTS

Two hundred and thirty-six women screened positive for GDM. At diagnosis, GDM pregnancies demonstrated higher adjusted fetal weight percentile than non-GDM pregnancies: (51.8 vs. 46.3, p = 0.008). This was driven by increases in the fetal abdominal circumference percentile in GDM compared with non-GDM pregnancies (55.3 vs. 46.2, p = <0.001). Early pregnancy HbA1c was higher in the GDM versus non-GDM group: (35.7 mmol/mol vs. 32.9 mmol/mol p = <0.01). A threshold for predicting excessive fetal growth was not identified in this cohort.

CONCLUSIONS

Accelerated fetal growth is evident prior to the diagnosis of GDM. There remains a need for suitable methods of early identification of pregnancies at high risk for early accelerated fetal growth due to GDM. First-trimester HbA1c was not useful in identifying these pregnancies.

NOVELTY STATEMENT

WHAT IS ALREADY KNOWN?: Recent research suggests excessive growth associated with GDM may begin prior to 28 weeks' gestation, when GDM is typically tested for WHAT THIS STUDY HAS FOUND?: Pregnancies affected by GDM are already subject to accelerated fetal growth in comparison to non-GDM pregnancies by way of higher estimated fetal weight and fetal abdominal circumference Neither first-trimester HbA1c nor plasma glucose was useful predictors of these outcomes WHAT ARE THE IMPLICATIONS OF THIS STUDY?: Highlights the emergence of excessive growth prior to detection of GDM Reinforces need for suitable methods of identifying such pregnancies in earlier gestation.

Effectiveness and cost-effectiveness of text messages with or without endowment incentives for weight management in men with obesity (Game of Stones): study protocol for a randomised controlled trial

BACKGROUND

Obesity increases the risk of type 2 diabetes, heart disease, stroke, mobility problems and some cancers, and its prevalence is rising. Men engage less than women in existing weight loss interventions. Game of Stones builds on a successful feasibility study and aims to find out if automated text messages with or without endowment incentives are effective and cost-effective for weight loss at 12 months compared to a waiting list comparator arm in men with obesity.

METHODS

A 3-arm, parallel group, assessor-blind superiority randomised controlled trial with process evaluation will recruit 585 adult men with body mass index of 30 kg/m² or more living in and around three UK centres (Belfast, Bristol, Glasgow), purposively targeting disadvantaged areas. Intervention groups: (i) automated, theory-informed text messages daily for 12 months plus endowment incentives linked to verified weight loss targets at 3, 6 and 12 months; (ii) the same text messages and weight loss assessment protocol; (iii) comparator group: 12 month waiting list, then text messages for 3 months. The primary outcome is percentage weight change at 12 months from baseline. Secondary outcomes at 12 months are as follows: quality of life, wellbeing, mental health, weight stigma, behaviours, satisfaction and confidence. Follow-up includes weight at 24 months. A health economic evaluation will measure cost-effectiveness over the trial and over modelled lifetime: including health service resource-use and quality-adjusted life years. The cost-utility analysis will report incremental cost per quality-adjusted life years gained. Participant and service provider perspectives will be explored via telephone interviews, and exploratory mixed methods process evaluation analyses will focus on mental health, multiple long-term conditions, health inequalities and implementation strategies.

DISCUSSION

The trial will report whether text messages (with and without cash incentives) can help men to lose weight over 1 year and maintain this for another year compared to a comparator group; the costs and benefits to the health service; and men's experiences of the interventions. Process analyses with public involvement and service commissioner input will ensure that this open-source digital self-care intervention could be sustainable and scalable by a range of NHS or public services.

TRIAL REGISTRATION

ISRCTN 91974895 . Registered on 14/04/2021.

Parental perceptions of the food environment and their influence on food decisions among low-income families: a rapid review of qualitative evidence

Background

The food environment within and surrounding homes influences family dietary habits with socio-economic areas at a nutritional disadvantage. Families’ perception of the food environment and how it influences their food decisions is less clear. This rapid review aimed to synthesise qualitative evidence of parental perspectives of the food environment and their influence on food decisions among disadvantaged families.

Method

Qualitative and mixed-methods peer-reviewed journal articles published after 2000, that explored the perspectives of low-income parents in relation to their food environment and how this impacted food decisions for families with children aged 2-17 years, were included in this review. Embase, Scopus and PsycINFO were the databases chosen for this review. Search strategies included seven concepts related to family, food, perceptions, influences, environment, socio-economic status and study type. Two independent reviewers screened sixty-four studies. Thematic synthesis was employed.

Results

Two thousand one hundred and forty five results were identified through database searching and 1,650 were screened. Fourteen articles that originated from the US, Australia and the UK were included in this review. No articles were excluded following quality appraisal. Child preferences, financial and time constraints, and location and access to food outlets were barriers to accessing healthy food. Parental nutrition education and feeding approaches varied but positive outcomes from interventions to address these behaviours will be short-lived if inequities in health caused by poverty and access to affordable and healthy food are not addressed. The reliance on social support from families or government sources played an important role for families but are likely to be short-term solutions to health and nutritional inequities.

Conclusions

This qualitative evidence synthesis provides an insight into the perceptions of low-income parents on the factors influencing food decisions. Findings have implications for public health and the development of effective strategies to improve the dietary habits of children of disadvantaged families. Sustainable changes to dietary habits for families on low-income requires policy responses to low income, food access and to the high cost of healthy foods.

A rapid review of factors influencing food decisions among economically disadvantaged families

Introduction

The importance of external and household family food environments in establishing healthy eating habits during childhood is well reported. Deprived areas are at a nutritional disadvantage due to the high prevalence of fast food outlets and convenience stores. Little is known about the impact of food environments on food-related behaviours of low-income families. This rapid review aimed to synthesise available qualitative evidence on parental perspectives of environmental factors that influence food planning, purchasing and processing among economically disadvantaged families with children.

Methods

This review included qualitative and mixed-methods studies published after 2000 from Europe, North America and Oceania. Search strategies included seven concepts: family, food, perceptions, influences, environment, socio-economic status and study type. Thematic synthesis was employed.

Results

Fourteen articles from the USA, Australia and the UK remained following screening by two reviewers. All parents had a desire to provide healthy food for their children, but they were impeded by child food preferences and beliefs about food behaviours and nutrition. In the external environment, food outlets/availability, cost and marketing influenced food choices amongst parents. Social determinants had a dominant negative influence on food decisions, including hectic daily schedules and time constraints and most importantly limited finances. Social support and support from nutrition programmes and cooking interventions had a positive influence on family food decisions.

Conclusions

This synthesis of qualitative evidence highlights the challenges and opportunities that low-income parents face to feed their families. Improvements in parental food choices and feeding behaviours can only be improved if inequities in health, such as access to affordable healthy food, are addressed.

Key messages

This review concluded that income, time constraints, food cost and limited food availability/outlets can have a negative effect on family food decisions. Social supports such as cooking programmes play a positive role in ensuring healthy food options for families.

Changes in food-related practices among families in Ireland as a consequence of COVID-19

Introduction

The COVID-19 pandemic has had an inordinate influence on people's lives, including impacts on food behaviours. This study explored the impacts of the COVID-19 crisis and ensuing public health restrictions on food-related practices of families living on a tight budget on the Island of Ireland.

Methods

Photovoice and creative mapping methods were used whereby parents were requested to take photos of factors influencing food-related decisions and draw maps of their food environments. These items were then used during qualitative interviews with 28 parents from across the Island of Ireland as a reference for discussions around the food environment and food decision-making processes of economically disadvantaged parents. Data were analysed using deductive thematic analysis.

Results

The findings were situated in Bronfenbrenner's Social Ecological Theoretical framework, conceptualising the COVID-19 crisis as an exogenous socio-historical factor that exerted significant influence on the food-related practices of families in Ireland. The pandemic and responses to it altered patterns of food purchasing, preparation, decision-making and consumption. Changes to practices included increased unhealthy snacking and grazing and consuming fewer meals outside the home. Participants on particularly low incomes relied more on benefits and subsidised food sources and consumed more cheap, processed and frozen foods.

Conclusions

This study provides insight into the impacts of the COVID-19 crisis on dietary habits. The observed changes to food practices may compound food insecurity and already high levels of obesity, particularly among children and young people, and have future implications on prevalence of nutrition-related conditions. This highlights the need for healthcare professionals and policy-makers to be cognisant of the mounting health issues that will need to be addressed in the wake of COVID-19.

Key messages

The COVID-19 crisis significantly impacted on family food related behaviours in Ireland.

Post-COVID health promoters should re-focus efforts on healthy eating initiatives.

Food Decisions of Low-Income Families in the Era of COVID-19: A Qualitative Exploration

Objectives

The first lockdown enforced in the United Kingdom to limit the spread of COVID-19 had serious financial consequences for some lower-income households, which were already at risk of suboptimal food choices. Particularly in Northern Ireland, where 10% of the population live in food insecure households, the pandemic has potentially further exacerbated the nutritional challenges experienced by low-income families. This paper aimed to explore the impact of the COVID-19 lockdown on food-related decisions as experienced by economically disadvantaged families in Northern Ireland, UK.

Methods

A qualitative study collected data through online individual interviews. Participation was open to parents of children 2–17 years old who self-identified as living on a tight budget in urban and rural areas of Northern Ireland. A sampling matrix enabled equal representation of single- and two-parent households, as well as younger

(&lt;12 y) and older children (&gt;12 y). Photovoice and participatory mapping techniques were employed to capture participant data. A thematic approach was utilised for data analysis.

Results

A total of 12 interviews were conducted. Five distinct themes were found, reflecting families’ food-related decisions that were affected by the COVID-19 lockdown: 1) food planning; 2) food purchasing; 3) meal preparation; 4) eating and feeding behaviours and 5) eating food prepared outside the house. Changes included an increase in home food preparation, but also in unhealthy snacking. Fear of being exposed to carriers of the virus led to infrequent food shopping and greater reliance on supermarket home deliveries. Long waiting times in-between food shops encouraged food planning but were also a barrier to providing daily fresh foods including fruit and vegetables to their families. Financial constraints were exacerbated during lockdown and led to a search for new ways to budget when food shopping. Food donations from the community and the government were important to maintain food security, particularly in single-parent families.

Conclusions

This study highlights that the COVID-19 lockdown influenced a broad range of dietary decisions of economically disadvantaged families and offers an insight into the nutritional challenges they experienced.

Funding Sources

The work was completed with financial support from internal funds of Queens University Belfast.

Volumetric laser endomicroscopy and its application to Barrett's esophagus: results from a 1,000 patient registry

Volumetric laser endomicroscopy (VLE) uses optical coherence tomography (OCT) for real-time, microscopic cross-sectional imaging. A US-based multi-center registry was constructed to prospectively collect data on patients undergoing upper endoscopy during which a VLE scan was performed. The objective of this registry was to determine usage patterns of VLE in clinical practice and to estimate quantitative and qualitative performance metrics as they are applied to Barrett's esophagus (BE) management. All procedures utilized the NvisionVLE Imaging System (NinePoint Medical, Bedford, MA) which was used by investigators to identify the tissue types present, along with focal areas of concern. Following the VLE procedure, investigators were asked to answer six key questions regarding how VLE impacted each case. Statistical analyses including neoplasia diagnostic yield improvement using VLE was performed. One thousand patients were enrolled across 18 US trial sites from August 2014 through April 2016. In patients with previously diagnosed or suspected BE (894/1000), investigators used VLE and identified areas of concern not seen on white light endoscopy (WLE) in 59% of the procedures. VLE imaging also guided tissue acquisition and treatment in 71% and 54% of procedures, respectively. VLE as an adjunct modality improved the neoplasia diagnostic yield by 55% beyond the standard of care practice. In patients with no prior history of therapy, and without visual findings from other technologies, VLE-guided tissue acquisition increased neoplasia detection over random biopsies by 700%. Registry investigators reported that VLE improved the BE management process when used as an adjunct tissue acquisition and treatment guidance tool. The ability of VLE to image large segments of the esophagus with microscopic cross-sectional detail may provide additional benefits including higher yield biopsies and more efficient tissue acquisition. Clinicaltrials.gov NCT02215291.

The Impact of a Policy-Based Multicomponent Nutrition Pilot Intervention on Young Adult Employee's Diet and Health Outcomes

PURPOSE

Evaluate the effect of a policy-based, multicomponent workplace diet intervention on young adult employees' diet and health.

DESIGN

A 6-month, single-armed pilot study with before and after assessments.

SETTING

Insurance company in Belfast, Northern Ireland.

PARTICIPANTS

Employees who worked at the company throughout the intervention period were included. Employees were excluded if pregnant, breast-feeding, or following a strict diet.

INTERVENTION

Multicomponent diet intervention: ban of unhealthy foods brought into the premises, free fruit, education, individual advice, and further support.

MEASURES

Mixed-methods approach: Diet-, health-, and work-related measures were assessed quantitatively. The campaign was evaluated quantitatively (via questionnaire) and qualitatively (via semistructured interviews).

ANALYSIS

Changes in measures were analyzed using paired samples t tests. Interviews were analyzed using thematic analysis.

RESULTS

Sixty (75.9%) staff completed all assessments. Males reduced their sugar intake on working days (-8.7% of total energy standard deviation [SD]: 20.1; P value <.01). Systolic blood pressure reduced in males and females (-3.3 SD: 9.9; P value <.05 and -8.0 SD: 7.7; P value <.001, respectively); 85.2% of staff strongly agreed/agreed that they appreciated the healthy eating ethos. This was supported by the qualitative analysis which furthermore suggested that the education, team support, individual advice, and free fruit were beneficial.

CONCLUSION

Influencing workplace policies and offering additional dietary support could lead to meaningful changes in employees' diet and health and may change workplace culture.

Ethical Issues in Social Media Research for Public Health

Social media (SM) offer huge potential for public health research, serving as a vehicle for surveillance, delivery of health interventions, recruitment to trials, collection of data, and dissemination. However, the networked nature of the data means they are riddled with ethical challenges, and no clear consensus has emerged as to the ethical handling of such data. This article outlines the key ethical concerns for public health researchers using SM and discusses how these concerns might best be addressed. Key issues discussed include privacy; anonymity and confidentiality; authenticity; the rapidly changing SM environment; informed consent; recruitment, voluntary participation, and sampling; minimizing harm; and data security and management. Despite the obvious need, producing a set of prescriptive guidelines for researchers using SM is difficult because the field is evolving quickly. What is clear, however, is that the ethical issues connected to SM-related public health research are also growing. Most importantly, public health researchers must work within the ethical principles set out by the Declaration of Helsinki that protect individual users first and foremost.

Does a diet high or low in fat influence the oxidation potential of VLDL, LDL and HDL subfractions?

BACKGROUND AND AIMS

High-fat diets have become increasingly popular for weight-loss, but their effect on the oxidation potential of lipoprotein subfractions has not been studied. Therefore, this study compared the effects of high-fat vs. low-fat weight reduction diets on this parameter.

METHODS AND RESULTS

Very-low, low- and high-density lipoprotein (VLDL, LDL & HDL) subfractions were isolated by rapid ultracentrifugation from 24-overweight/obese subjects randomised to a high- or low-fat diet. The lipoprotein subfractions were assessed for oxidation potential by measuring conjugated diene (CD) production and time at half maximum. We found a significant between-group difference in oxidation potential. Specifically, a high-fat diet led to increased CD production in VLDL(A-D) and HDL(2&3), and a prolongation of time at half maximum. Within-group differences found that CDs increased in VLDL(A&D), LDL(I-III) and HDL(2&3) in the high-fat group and fell in VLDL(A-C) and HDL(2&3) and increased in LDL(I&II), in the low-fat group. Furthermore, following both diets all lipoprotein subfractions, except LDL(II) in the low-fat group, were protected against oxidation.

CONCLUSION

These results demonstrate that at first glance, a high-fat diet may be indicative of having heart-protective properties. However, this may be erroneous, as although the time for oxidation to occur was prolonged, once this occurred these lipoproteins had the potential to produce significantly more oxidised substrate. Conversely, a low-fat diet may be considered anti-atherogenic, as these subfractions were protected against oxidation and mainly contained fewer oxidised substrate. Thus, increased fat intake may, by increasing the oxidation product within lipoprotein subfractions, increase cardiovascular disease.

Effect of aging on regional cerebral blood flow responses associated with osmotic thirst and its satiation by water drinking: a PET study

Levels of thirst and ad libitum drinking decrease with advancing age, making older people vulnerable to dehydration. This study investigated age-related changes in brain responses to thirst and drinking in healthy men. Thirst was induced with hypertonic infusions (3.1 ml/kg 0.51M NaCl) in young (Y) and older (O) subjects. Regional cerebral blood flow (rCBF) was measured with positron emission tomography (PET). Thirst activations were identified by correlating rCBF with thirst ratings. Average rCBF was measured from regions of interest (ROI) corresponding to activation clusters in each group. The effects of drinking were examined by correlating volume of water drunk with changes in ROI rCBF from maximum thirst to postdrinking. There were increases in blood osmolality (Y, 2.8 +/- 1.8%; O, 2.2 +/- 1.4%) and thirst ratings (Y, 3.1 +/- 2.1; O, 3.7 +/- 2.8) from baseline to the end of the hypertonic infusion. Older subjects drank less water (1.9 +/- 1.6 ml/kg) than younger subjects (3.9 +/- 1.9 ml/kg). Thirst-related activation was evident in S1/M1, prefrontal cortex, anterior midcingulate cortex (aMCC), premotor cortex, and superior temporal gyrus in both groups. Postdrinking changes of rCBF in the aMCC correlated with drinking volumes in both groups. There was a greater reduction in aMCC rCBF relative to water drunk in the older group. Aging is associated with changes in satiation that militate against adequate hydration in response to hyperosmolarity, although it is unclear whether these alterations are due to changes in primary afferent inflow or higher cortical functioning.

Phase I/II trial of bortezimib and pemetrexed in patients with advanced non-small cell lung cancer

18145

Background: Bortezomib (Vc) is a novel proteosome inhibitor with activity in several malignancies including multiple myeloma, mantle cell lymphoma, and NSCLC. In NSCLC, Vc has additive activity combined with carboplatin and gemcitabine in first line and with docetaxel in second line treatment. Pemetrexed (P) is active in NSCLC and preclinical data suggests a pro-apoptotic synergy between Vc and P. Therefore, we initiated a phase I/II dose finding study of Vc + P in previously-treated patients (pts) with advanced or metastatic NSCLC. Methods: Fifteen pts have been accrued to 3 of 4 planned dose levels of Vc + P. Starting doses (and # pts treated) were Vc 1.4 mg/m2 day 1 & 8 + P 400 mg/m2 day 1 every 3 weeks (3 pts). The 2nd and 3rd dose levels were Vc 1.6 mg/m2 day 1 & 8 + P 500 mg/m2 day 1 (8 pts, 5 new + 3 from dose level 1) and Vc 1.8 mg/m2 day 1 & 8 + P 500 mg/m2 day 1 (7 pts). Results: 15 pts are evaluable for response and toxicity and include 8 males, 7 females, median age 67 (range, 55–82), PS 0/1 (3/12 pts), median of 2 prior therapies (range 1–3). Confirmed PRs occurred in 2 pts (13%) and stable disease in 5 (33%). Dose limiting toxicities consisted of grade 4 fatigue (1 pt) and neutropenia/fever (1 pt) at dose level 2, and grade 3 abdominal pain and fatigue (1 pt) and grade 3 diarrhea and vomiting (1 pt) at dose level 3. Conclusions: The above combination is safe at the doses tested thus far and active in pts with heavily pretreated, advanced NSCLC. We are currently exploring Vc 2.0 mg.m2 Day 1 & 8 + P 500 mg/m2 day 1 every 3 weeks to determine the MTD and plan a multi-site Phase II study to determine response rate and survival in a larger pt population.

No significant financial relationships to disclose.

Treatment of psychogenic polydipsia: comparison of risperidone and olanzapine, and the effects of an adjunctive angiotensin-II receptor blocking drug (irbesartan)

OBJECTIVE

Our objective was to determine the outcome of novel strategies in managing a case of severe polydipsia.

CLINICAL PICTURE

The patient was a 39-year-old male with a 20-year history of paranoid schizophrenia who, despite only mild residual psychotic symptoms, had been hospitalized for the previous 10 years because of severe polydipsic behaviour complicated by water intoxication.

TREATMENT

Novel antipsychotic agents, risperidone and olanzapine, as well as the specific angiotensin-II receptor blocking drug, irbesartan were employed at selected intervals in a study lasting nearly 3 years. A strict behavioural management programme was ongoing, in which diurnal weight change and the number of breaches of weight limits, requiring management in a low-stimulus environment, were documented on a daily basis. Summary measures of diurnal weight change and behavioural intervention were charted against changes in treatment.

OUTCOME

Polydipsic behaviour improved on risperidone up to 4 mg daily, but was not sustained. Olanzapine was similarly successful in stabilizing polydipsia, and improvement was achieved with the addition of irbesartan.

CONCLUSION

We suggest that the D2-sparing profiles of receptor binding achieved with low-dose risperidone and olanzapine may account for this beneficial effect. The benefit derived with irbesartan implicates the involvement of brain angiotensin systems centrally in helping to regulate drinking behaviour.

History of the professional councils of the National Kidney Foundation

As the Councils move toward the new millennium, efforts to improve outcomes for patients with renal disease will be at the forefront. Each council has established a commitment to improving the quality of life for these individuals. Toward this goal, the CNNT, the CRN, and the CNSW will each propose programs to the NKF for improving the knowledge and skills of the professionals within these councils, promoting research within the respective scope of these professions, and working together to bring a better understanding of the issues confronted by the patients and the professionals as well. As an example of the combined effort of the Councils, the first joint project of the century will be to bring the communications packages of each council under a common framework by joining the newsletters of each council. It is an exciting time to be part of the NKF. As a professional in the renal community, being a part of the CNNT, the CRN, or the CNSW offers a professional enrichment and opportunities to participate in making lives better for those with renal disease.

Targeted insertion of a lacZ reporter gene into the mouse Cer1 locus reveals complex and dynamic expression during embryogenesis

The mouse Cer1 (mCer1, Cer-l, Cerr1) gene encodes one member of a family of cytokines structurally and functionally related to the Xenopus head-inducing factor, Cerberus (xCer). We generated a mouse line in which the Cer1 gene was inactivated by replacing the first coding exon with a lacZ reporter gene. Mice homozygous for this allele (Cer1(lacZ)) showed no apparent perturbation of embryogenesis or later development. However, the lacZ reporter revealed a number of hitherto uncharacterised sites of Cer1 expression in late fetal and adult tissues. Preliminary analysis suggests that Cer1 is not essential for their morphogenesis, differentiation, or homeostasis.

Neuroimaging evidence implicating cerebellum in support of sensory/cognitive processes associated with thirst

Recent studies implicate the cerebellum, long considered strictly a motor control structure, in cognitive, sensory, and affective phenomenon. The cerebellum, a phylogenetically ancient structure, has reciprocal ancient connections to the hypothalamus, a structure important in vegetative functions. The present study investigated whether the cerebellum was involved in vegetative functions and the primal emotions engendered by them. Using positron emission tomography, we examined the effects on the cerebellum of the rise of plasma sodium concentration and the emergence of thirst in 10 healthy adults. The correlation of regional cerebral blood flow with subjects' ratings of thirst showed major activation in the vermal central lobule. During the development of thirst, the anterior and posterior quadrangular lobule, lingula, and the vermis were activated. At maximum thirst and then during irrigation of the mouth with water to alleviate dryness, the cerebellum was less activated. However, 3 min after drinking to satiation, the anterior quadrangular lobule and posterior cerebellum were highly activated. The increased cerebellar activity was not related to motor behavior as this did not occur. Instead, responses in ancient cerebellar regions (vermis, fastigal nucleus, archicerebellum) may be more directly related to vegetative and affective aspects of thirst experiences, whereas activity in neocerebellar (posterior) regions may be related to sensory and cognitive aspects. Moreover, the cerebellum is apparently not involved in the computation of thirst per se but rather is activated during changes in thirst/satiation state when the brain is "vigilant" and is monitoring its sensory systems. Some neocerebellar activity may also reflect an intentionality for gratification by drinking inherent in the consciousness of thirst.

Neuroimaging of genesis and satiation of thirst and an interoceptor-driven theory of origins of primary consciousness

There are defined hypothalamic functions in the genesis of thirst, but little is known of the cortical processes subserving consciousness of thirst notwithstanding the medical disorders that occur in psychiatric illness, addiction, and the attested decline of thirst with aging. In 10 adult males, positron emission tomography scans were made (i) during genesis of moderate thirst by infusion of i.v. hypertonic saline 0.51 M, (ii) after irrigation of the mouth with water to remove the sensation of dryness, and (iii) 3, 14, 45, and 60 minutes after drinking water to fully satiate thirst. The correlation of regional cerebral blood flow with thirst score showed the major activation to be in the posterior cingulate. Maximum thirst sensation evoked 13 highly significant activations and 9 deactivations in cingulate and parahippocampal gyri, insula, thalamus, amygdala, and mesencephalon. It is possible that cingulate sites (Brodmann's areas 32, 24, and 31) that persisted with wet mouth but disappeared immediately after drinking to satiation may have an important role in the consciousness of thirst. Consciousness of thirst, a primal vegetative emotion, and satiation of thirst appear to be subserved by phylogenetically ancient brain regions. This is salient to current discussion on evolutionary emergence of primary consciousness.

Correlation of regional cerebral blood flow and change of plasma sodium concentration during genesis and satiation of thirst

Positron emission tomography studies were conducted during genesis of moderate thirst by rapid i.v. infusion of hypertonic saline (0.51 M) and after satiation of thirst by drinking water. The correlation of regional cerebral blood flow with the change in the plasma Na concentration showed a significant group of cerebral activations in the anterior cingulate region and also a site in the middle temporal gyrus and in the periaqueductal gray. Strongest deactivations occurred in the parahippocampal and frontal gyri. The data are consistent with an important role of the anterior cingulate in the genesis of thirst.

Endoscopic screening for dysplasia and mucosal aneuploidy in adolescents and young adults with childhood onset colitis

OBJECTIVES

In adults, the premalignant nature of ulcerative colitis (UC) has long been accepted. Currently there is increasing concern that Crohn's disease (CD) may be equally premalignant. As a consequence, most adults with long-standing UC and many with chronic CD are enrolled in ongoing endoscopic cancer surveillance programs. In contrast, the risk of colonic cancer in adolescents and young adults with either form of colitis is less well recognized, and the need for dysplasia and cancer screening in this population has not been systematically evaluated. We therefore report the prospective results of colonoscopic cancer screening in such a young population.

METHODS

Thirty-five adolescents and young adults with long-standing colitis (18 UC, 17 CD; 21 +/- 3 yr old, 11 +/- 3 yr colitis duration) underwent colonoscopic cancer screening. All had multiple biopsies for flow cytometry and light microscopy.

RESULTS

Seven subjects had aneuploidy (3/18 UC, 4/17 CD). Of these seven, only two had dysplasia [one high grade (UC), one low grade (CD)]. One additional subject had indefinite dysplasia with normal flow cytometry. The remaining 27 subjects had both normal flow cytometry and light microscopy. Five of the seven aneuploid subjects underwent surgery within 1 yr of screening. Four, including both subjects with dysplasia, had no evidence of colon cancer at surgery. However, a 24-yr-old female with a 14-yr history of UC and no evidence of dysplasia or cancer at screening had a Dukes C adenocarcinoma.

CONCLUSIONS

Adolescents and young adults with childhood onset UC or CD are at risk for aneuploidy, dysplasia, and colon cancer. Aneuploidy can be evident 10 yr after the onset of colitis and in patients as young as 16 yr of age. Therefore, the risk for colon cancer in patients with childhood onset colitis must be based on the duration of the illness, not on their chronological age. Incorporation of flow cytometry into an endoscopic screening protocol appears to enhance the ability to identify individuals at highest risk for colon cancer.

Differential effects of physiological versus pathophysiological plasma concentrations of epinephrine and norepinephrine on ketone body metabolism and hepatic portal blood flow in man

Few studies that have examined the effects of catecholamines on ketogenesis have considered the effects of catecholamines on hepatic portal blood flow. Since hepatic blood flow is a major determinant of hepatic ketogenesis (via modification of free fatty acid availability), interpretation of these studies is difficult. To better define the relative contributions of these variables, we studied the effects of physiological and pathophysiological plasma concentrations of epinephrine and norepinephrine on plasma ketone body concentrations and hepatic portal blood flow in controlled paired studies in young healthy male volunteers. To assess the effects of physiological catecholamine concentrations, each of eight subjects received 60-minute sequential infusions of epinephrine (10 ng/kg/min) and norepinephrine (32.5 ng/kg/min) together with a control infusion of heparin (0.4 U/kg/min) separated by 60-minute washout periods. Similar increments in plasma nonesterified fatty acid ([NEFA] to approximately 1 mmol/L) were observed during each infusion. The ketotic ratios, calculated as the ratio of plasma ketone bodies to fatty acids integrated above baseline for 90 and 120 minutes, respectively, for epinephrine and norepinephrine infusions were both significantly greater (P < .005 for each) than for the heparin control infusion. To assess the effects of pathophysiological plasma catecholamine concentrations, each of eight subjects also received sequential 60-minute infusions of epinephrine 60 ng/kg/min, norepinephrine 80 ng/kg/min (plus heparin 0.1 U/kg/min), and a separate control infusion of heparin with or without Intralipid (KabiVitrum, Alameda, CA). Whereas integrated plasma fatty acid levels were approximately twofold greater than those observed in the physiological protocol, the absolute integrated ketone body response to the pathophysiological concentration of epinephrine was significantly lower than that observed for the physiological dose of the hormone (P < .05). In contrast, the ketotic ratio for norepinephrine was significantly greater (P < .005) than for both epinephrine and the control infusion of heparin with or without Intralipid. Significant (P < .01) increases above baseline fasting levels were observed in plasma glucose and immunoreactive insulin concentrations during infusion of pathophysiological concentrations of epinephrine. Because of the technical difficulties of simultaneously measuring portal blood and sampling blood frequently, studies were repeated in six additional subjects using noninvasive image-guided flowmetry to measure percentage changes in hepatic portal blood flow during catecholamine infusion. Norepinephrine reduced hepatic portal blood flow significantly at the low-physiological concentration by 12% (P < .05) and at the pathophysiological concentration by 18% (P < .05). In summary, (1) both epinephrine and norepinephrine were associated with significant ketotic effects at physiological plasma concentrations; and (2) when infused at pathophysiological concentrations, only norepinephrine exerted a significant additional ketotic effect. Since norepinephrine has a significant simultaneous effect of reducing hepatic portal blood flow, we conclude that previous studies may have underestimated the effect of norepinephrine on hepatic ketogenesis.

Selective expansion of specific T cell receptors in the inflamed colon of Crohn's disease

To identify disease-specific T cell changes that occur in Crohn's disease (CD), the T cell receptor BV repertoires of lamina propria lymphocytes (LPL) isolated from both the inflamed and "disease-inactive" colons of seven CD patients were compared by the quantitative PCR and DNA sequence analysis. It was observed that the BV repertoires of LPL isolated from the disease-active and disease-inactive parts of the colon from the same individual were very different. Furthermore, nearly all of the differences occurred in CD4+ LPL, with very few differences in the CD8+ population of LPL. Although the pattern of BV segments that was increased in disease-active tissue relative to disease-inactive tissue was different for all seven CD patients, there were several BV segments that increased uniformly in the disease-active tissue of all seven individuals. CDR3 length analysis and DNA sequencing of these BV segments revealed that in six of the seven CD patients there was a striking degree of oligoclonality that was absent from disease-inactive tissue of the same individual. These observations suggest that at least some of the inflammation in CD is the result of responses by CD4+ T cells to specific antigens. The isolation of such inflammation-specific CD4+ T cells may make it possible to identify the antigens that are responsible for the inflammatory process in CD and provide a better understanding of its pathogenesis.

CD4+ cell oligoclonality in Crohn's disease: evidence for an antigen-specific response

To identify disease-specific T cell changes that occur in Crohn's disease (CD) the T-cell receptor (TCR) BV repertoires of lamina propria lymphocytes (LPL) from both disease-active and disease-inactive colonic tissue of three CD patients were compared by a quantitative polymerase chain reaction (qPCR) and CDR3 length analysis. It was observed that the BV repertoires of LPL isolated from the disease-active and disease-inactive parts of the colon of the same individual were different, and most of the differences occurred in CD4+ LPL with very few differences in the CD8+ populations of LPL. Although the pattern of BV segments that was increased in disease-active relative to disease-inactive tissue was different for all three CD patients, there was an increase in the levels of BV11, 13S2, 15, 16, and 17 segments in the disease-active tissue of all three patients. Standard CDR3 length analysis of BV11, 13S2, 15, 16, and 17 segments revealed that in two of the three CD patients there was a striking degree of TCR oligoclonality in the disease-active tissue that was absent from disease-inactive tissue of the same individual. Additional differences between the disease-active and disease-inactive tissues were observed using a more refined method of CDR3 length analysis, which employs BV- and BJ-specific primers. These observations suggest that at least some of the inflammation in CD is the result of responses by CD4+ T cells to specific antigens.

Crohn's disease is accompanied by changes in the CD4+, but not CD8+, T cell receptor BV repertoire of lamina propria lymphocytes

To identify disease-specific T cell changes that occur in Crohn's disease (CD), the T cell receptor (TCR) BV repertoires of lamina propria lymphocytes (LPL) isolated from the diseased colon of seven CD patients and eight controls were determined by semiquantitative polymerase chain reaction (qPCR). As an internal control for the effects of HLA and other genes on the TCR repertoire, the BV repertoires of peripheral blood lymphocytes (PBL) from the same individuals were similarly determined and used for comparison. It was observed that the BV repertoires of LPL and PBL within the same individual were very different in both the CD and control groups. However, the CD4+, but not CD8+, repertoires of LPL and PBL differed to a much greater extent in the CD group than in the control group. Furthermore, in each CD patient there was a unique pattern of BV segments which were increased in the CD4+ LPL repertoire relative to that in PBL. These observations suggest that the inflammatory process in CD involves responses by specific CD4+ T cells to specific antigens. The isolation of such inflammation-specific CD4+ T cells may make it possible to identify the antigens which are responsible for the inflammatory process in CD and provide a better understanding of its pathogenesis.

Comparisons of T cell receptor (TCR) V beta repertoires of lamina propria and peripheral blood lymphocytes with respect to frequency and oligoclonality

The TCR repertoires of CD4+ and CD8+ lamina propria and peripheral blood lymphocytes (PBL) were compared with respect to V beta frequencies and oligoclonality. Disease-free colon specimens and paired peripheral blood samples were obtained from eight adult patients undergoing surgical resections for colorectal carcinoma. Mononuclear cell were isolated from the lamina propria and peripheral blood and separated into CD4+ and CD8+ cells by immunomagnetic adsorbtion. Analysis of V beta frequencies by qPCR revealed that PBL and lamina propria lymphocytes (LPL) from the same individual have very different repertoires, especially within the CD8+ population. Furthermore, CD8+, but not CD4+, LPL display extensive oligoclonality, similar to that which has previously been reported for CD8+ PBL. However, the oligoclonal receptors observed in CD8+ LPL are, in general, distinct from those observed in CD8+ PBL, and differ for each individual. These observations indicate that the TCR repertoires of LPL are as diverse as PBL, and suggest that LPL and PBL are normally exposed to different sets of antigens. In addition, these observations provide a baseline for examining the effects of various disease states and environmental insults on the LPL repertoire.

What can they teach you? Interview by John McCormack

When Michael Jordan traded in his high-tops for cleats, people had their doubts. What skills could this high-flying king of the court bring to the baseball diamond? Ask the players for the Birmingham Barons, the minor league team that he joined last year. Jordan didn't bring sophisticated baseball skills to the organization, but he was able to teach his new peers--all lifelong baseball players--about physical conditioning, competitiveness, mental preparation, and the ups and downs of fame. When materials managers from other industries sign on to a hospital team, there may be doubts about whether their skills are transferable. But, like Jordan, they bring to the team unique experiences and perspectives that can enhance the game. Hospitals that hire managers from other disciplines often find that these people bring bold new ideas to the organization. Their special skills could even help improve the performance of longtime players in the health care arena. We recently spoke with four hospital managers who immigrated to health care from other industries. Read their stories and you, too, might see your job in a whole new way.

Appropriate response to pneumococcal vaccine in celiac sprue

Hyposplenism as a complication of celiac sprue confers an increased risk of pneumococcal sepsis, but such patients do not routinely receive pneumococcal vaccine despite reports of overwhelming pneumococcal sepsis. Because antibody response in these patients has not been previously assessed, we measured pre- and postvaccination levels in 10 patients with documented sprue. All demonstrated appropriate acute antibody responses to a polyvalent pneumococcal vaccine. Vaccination of all patients with celiac sprue seems appropriate.

Crohn's disease and colorectal carcinoma: rectal cancer complicating longstanding active perianal disease

OBJECTIVES

Reports of Crohn's disease (CD)-associated colorectal carcinoma are being cited in the medical literature with increasing frequency. Our aim was to identify subgroups of patients with risk factors that may account for this.

METHODS

We reviewed the medical records of 16 patients with the simultaneous diagnosis of CD and colorectal carcinoma and, in addition, reviewed previously reported cases of CD-associated colorectal carcinoma.

RESULTS

Eight male and eight female patients presented with 18 carcinomas: four right colon, four transverse, two descending colon, and eight rectal lesions. Median age at presentation was 48 yr. The mean duration of CD before presentation of carcinoma was 19.7 yr. Two lesions were discovered in strictured bowel segments. Two patients had multiple cancers. One had simultaneous cecal and left colon adenocarcinomas. The other underwent resection of a right colon lesion and 5 yr later presented with transverse colon carcinoma. Eight patients had rectal cancer; all were diagnosed preoperatively. Six of these patients had a history of severe perianal CD. Six had undergone multiple incision and drainage procedures for perirectal abscesses and fistulas. Two developed malignancies in defunctionalized rectal stumps. One of these patients presented with simultaneous squamous rectal carcinoma and papillary bile duct cholangiocarcinoma.

CONCLUSIONS

Gastrointestinal malignancy in association with CD has been reported. Symptoms of chronic inflammatory disease may obscure clinical manifestations of occult malignancy and thereby delay diagnosis. Crohn's patients with long-standing anorectal or perianal disease and stricture may well warrant surveillance endoscopy and biopsy of involved areas with the hope of earlier detection and treatment of these rectal cancers.

DNA testing for fragile X syndrome in schools for learning difficulties

Fragile X syndrome is the most common inherited cause of mental retardation. Early diagnosis is important not only for appropriate management of individuals but also to identify carriers who are unaware of their high risk of having an affected child. The disorder is associated with a cytogenetically visible fragile site (FRAXA) at Xq27.3, caused by amplification of a (CGG)n repeat sequence within the gene at this locus designated FMR1. Clinical and molecular studies have been undertaken to screen for fragile X syndrome in 154 children with moderate and severe learning difficulties of previously unknown origin. Southern blot analysis of peripheral blood showed the characteristic abnormally large (CGG)n repeat sequence associated with fragile X syndrome in four of the 154 children. The findings were confirmed by cytogenetic observation of the fragile site and by further molecular studies. The families of the affected children were offered genetic counselling and DNA tests to determine their carrier status. These findings show that there are still unrecognised cases of fragile X syndrome. Given the difficulty of making a clinical diagnosis and the implications for families when the diagnosis is missed, screening in high risk populations may be justified. The issues involved in screening all children in special schools for fragile X syndrome are discussed.

Prospective analysis of colorectal carcinoma. Determination of an age-site and stage relationship and the correlation of DNA index with clinicopathologic parameters

PURPOSE

A prospective study of colorectal cancer (1987-1991) using flow cytometry was performed to determine the relationship of age with DNA index (DNA-I), sites of disease, Dukes stage, grade, and survival.

METHODS

The flow cytometry was performed on 138 fresh, unfixed, surgical specimens using 4',6'-diamidino-2-phenylindole, a DNA fluorochrome.

RESULTS

The mean age was 66.9 (42.8 percent > or = 70; range, 22-92; median, 68) years, and 48.6 percent were female. The patients' stages were (in percent): A, 4.4; B, 53.0; C, 38.2; D, 4.4. Tumor grades of differentiation (in percent) were well, 14.4; moderate, 68.9; poor, 16.7; and sites (in percent) were: rectum, 19.6; sigmoid/left, 50.7; transverse/right, 29.0. Aneuploidy (DNA-I not equal to 1.0; CV, 3.5 percent) was found in 58.8 percent. Age (by decade of presentation) was compared with site and Dukes stage. Older patients had more transverse/right-sided lesions (P = 0.003). Patients with Dukes C and D tumors had a lower age (by decade of presentation) than patients with B2 lesions (P = 0.03). Age was not related to DNA-I or grade or DNA-I with sex, grade, site, stage, or survival (P > 0.05).

CONCLUSIONS

This prospective study suggests that colorectal cancer tends to present at an earlier stage and in the more proximal colon in the older population. Because right-sided lesions are beyond the reach of sigmoidoscopy, these findings have prognostic and screening implications.